MPs were debating accountability in the NHS following the Mid-Staffs scandal today, and as part of that, the argument about who – if anyone – should be held responsible continues to rumble on. Charlotte Leslie and many of her Tory colleagues want to see Sir David Nicholson gone (and The Telegraph‘s Robert Winnett reports that senior government figures are considering a route by which he can exit). But the focus of Jeremy Hunt and other Conservatives is on Andy Burnham instead. Today Hunt said:

‘[Nicholson] does bear some responsibility. He said himself ‘we lost our focus’, he has apologised and has been held to account by this House and others. But I don’t believe that he bears total responsibility, or indeed personal responsibility for what happened.’

Hunt said Nicholson had ‘consistently warned’ of the dangers of hitting targets without improving care, and added that ‘others do bear a far more direct responsibility’, including the board of the Trust. But he also rejected the argument advanced by Andy Burnham that ‘there were cases where the underlying culture of the NHS didn’t change’ in spite of ‘well-meaning’ policy changes. Hunt said that ‘Labour did make three huge policy mistakes and he must accept that it is not simply a question of government policy not being implemented’. Hunt also had a little moan about the way Labour likes to focus on the motives of the current government in reforming the NHS rather than the detail.

The shift from ‘there should be no scapegoats’ to ‘Labour has questions to answer’ happened last week. The Prime Minister’s PPS, Sam Gyimah, included a question about Labour and the Mid Staffs scandal on the list of suggestions for PMQs that he sent to Tory MPs. In the end, it fell to a Labour MP to raise Nicholson, which allowed David Cameron to say ‘other people, frankly, should be thinking of their positions too’.

Burnham was understandably anxious about what the Francis Report might say about him, although in the end the final publication made more comfortable reading than he’d anticipated. He took care today to say that Labour ‘will face up to what went wrong… and I repeat that apology for the families of those who suffered appalling abuse and neglect’. He also criticised ‘a tendency to pull the shutters down’ in the NHS when complaints appeared. But his argument that good policies weren’t being implemented was not particularly convincing.

Actually, if Labour were the party in government now and Mid-Staffs had happened on the Tories’ watch, it’s hard to imagine today’s debate being quite so polite. But Hunt dismissed ongoing concerns about Nicholson and aimed again at Burnham. Nicholson may need to stick around to implement the complex web of NHS reforms in the next few weeks, but the Tories must beware of attacking just one group that was involved, rather than all groups. Labour does have questions to answer. But it’s not the only name in this row. Jeremy Hunt wants to paint himself as a ‘patients’ champion’, and to that end he needs to look at those other managers involved in Mid-Staffs. He made some moves on this today, attacking the board members at the Trust who ‘seem to have melted into thin air’. There is a danger that the Conservative party turns this issue into a political game if it just focuses on Burnham and other Labour figures. So it does need a plan for Nicholson, even if it involves him implementing the reforms and then going in the summer.

It is of great sadness to me that political dogma manages to blank out any consideration that methods and experience from elsewhere could ever be applicable in the UK.

This is particularly so in the NHS, where the dogma that the government has to be directly responsible from taxation for the supply of health care have been inbuilt for so long.

This combined with “free at the point of use” is particularly damaging. What is even more amazing is the fact that so little in the NHS is actually free at the point of use, prescription charges, dental costs (if available on the NHS at all) and the endemic rationing, which itself translates into huge costs for the individual patient.

So why are things so different here in France. These are a few simple conclusions:

A The system is run on an insurance basis based on income supported and mandated by the state but with no direct participation by the state: the insurers are even competitive amongst themselves. The system has state protection for the low paid, the chronically ill, pensioners, children, etc. Top up insurance can be purchased out-with the system to cover the balance not paid for within the system.

The insurance organisation reports on all transactions and produces an annual account for each of its insured clients showing the premiums paid and the amounts disbursed on behalf of the insured so it is abundantly clear the actual costs of health services.

B “Free at the point of use” in the UK is a fallacy and only encourages people to use UK medical services unnecessarily and to regard the access to such services as being as of right. The public perception of that “right” may even be one of the causes of violence towards hospital staff in the UK A+E departments.

C Here the modest fee €22 payable to the GP, most of which is normally reimbursed later, is a disincentive to time wasters and malingerers, even in this country of hypochondriacs. It is amazing how effective the cash flow consequences of having to pay the doctor his €22 fee, even though it can be claimed back later, is in making sure that patients really need to be there. Of course anyone with a noted chronic condition or socially disadvantaged will be reimbursed 100% and if he has a Carte Vitale the GP is credited automatically without money changing hands. The GP’s or consultants charged fees are his income and he like other health professionals are in overt competition with each other.

D Here the €22 / visit is the GP’s income (not a capitation fee) so he will welcome patients and be attentive as he should, (in a competitive manner with his colleagues).

E The Pharmacist will provide over the counter advice and drugs for almost any common aliment. He will also provide prescription drugs (un-reimbursed) if needed at his discretion. Thus the load on the GP is much reduced.

F The local pharmacist also doubles as the hospital pharmacy for any outpatient day patient procedures such as and it is the patient’s responsibility to get the drugs prescribed before and take them to his appointment.

G All the providers in the system, the GPs, consultants, diagnostic labs, district nurses, etc. are independent organizations or self-employed private contractors within the system. They normally work at proscribed fee scales.

H The contractors in the system choose their mode of working from the point of view of their own businesses and lifestyle choices, within those fee scales. This results in the outcomes most of which would be remarkable in the UK except in the costly private sector:

• The GP (General Practitioner) has no secretary and no appointment system. Turn up when you need and wait perhaps 15 minutes on a busy day.

• GPs are not paid by a capitation fee based on patient numbers but only on their actual patient appointments, (a piece-work basis just like UK dentists remuneration). And only recently a system of affiliating patients to GP’s has been introduced, before that it was totally open to the choice of the patient on any particular occasion

• The patient also has the choice of which consultant to see but the GP will always recommend the one he considers suitable. It is not necessary to get a referral via a GP to be able to see a consultant, just phone up and make an appointment.

• The GP will also be happy to make home visits: the reimbursed charge is rather more.

• The dentist has no dental nurse and runs the practice single-handed. A significant proportion of his fees are reimbursed to the patient.

• The busy cardiology practice with three consultants has just one administrative assistant.

• The district nurse will turn up at on the doorstep to take a blood sample at 7.00 am in the morning for a fee of €6.35 (reimbursed).

• The consultant dermatologist answers his own phone and makes his own appointments without any need for administrative help.

• As well as doing major surgery, the consultant orthopaedic surgeon does his own minor splint work on the spot.

• Etc. etc.

Thus the administrative load created by centralised control and rationing of consultants and hospital appointments does not exist.

I As separate private contractors, all health professionals work as if “their time was their money”. Most UK hospital consultants are already private contractors as well as being well-paid part-time government employees. The difference in France is that their Health service fees are regulated by the government and controlled by the insurers.

J There is a real emphasis on preventative medicine and prompt treatment is considered to be economically worthwhile. Thus certainly in my experience waiting lists just do not exist.

K Admittedly there is an abundance of medically qualified people in the system and indeed there is a degree of competition between them. According to OECD figures, there are almost twice as many medically qualified professionals per head of population as in the UK health service.

L The medics run the hospitals and other facilities not the government nor the administrators. They see the benefit of having an absolute minimum of administrative overheads. Those that exist are mainly involved with the ensuing that the Insurance organisations are charged correctly. This also means that there are no artificial limits placed on maximizing the use of expensive capital equipment and the hospital installations. Their seems to be no multitier administrative structure of boards, trusts and quangos to control the system. That costly administrative load is eliminated.

M Also, crucially, as the government is not supplying the service, the state does not own the product of the service nor most importantly the patients’ medical records:

• Patients have bought the service either directly at the proscribed rates or via their insurance and they are therefore the owners of the results.

• Responsibility for the ownership of such records is reasonably unloaded on to the patient.

• This eliminates another whole swathe of administrative costs. And as there is no government duty of care with regard to patient records, there is no need / apparent obligation / or demand to create an expensive nationwide database of everyone’s medical records.

• I believe that it is only in very few chronic cases that longstanding records are essential for treatment.

• Any minimal useful information (such as the fact that I am diabetic, allergies, blood type, etc.) is retained on the chip of my Carte Vitale. The Carte Vitale is a type of credit card with a chip, that is used to organise the data required for my insurer to pay the sums necessary to the whichever part of the health system I have used. The card can be updated automatically with any changed circumstances at a terminal at any pharmacy. This seems to be a truly efficient use of Information Technology as applied to the health service.

• Along with a pragmatic hands-on approach to consultant referral and appointment making, the need for a failed £20 billion government organised Health IT project collating everyone’s medical records is eliminated at a stroke.

And here a much simpler IT system works and it has been working for decades. Nobody in the UK seemed to have bothered to cross the channel to ask how it worked.

I certainly I believe that health outcomes for a similar percentage expenditure of GDP are much better here than in the UK. The NHS is certainly not the only way of organizing a health service and the clear evidence is just across the channel.

The care about hospital infections is particularly impressive. This is because the staff all know that it would be quite possible for patient to chose to go elsewhere and therefore having an outbreak of MRSA, C Difficile, etc. would disastrous for the business of the hospital and thus their livelihoods.

The additional complexity of GPs (as opposed to care trusts) controlling and being limited by their budgets in what they can provide as drugs, treatments or referrals does not exist. The spending on care seems to be much more laisser faire. The professionals are trusted, so those other tiers of administration are non-existent.

The system does not seem mind that it patients are old. The aging like me are treated with a lot of respect and are sincerely cared for. Going to hospital here holds no fears, I am very glad even as someone with a UK medical background that I do not have to face the prospect in the UK.

So in effect everyone in France pretty well gets a Private Quality service provided at costs similar to the Nationalised service in the UK.

The Nation’s Health not the National Health Service should be the priority of government.

As someone who worked in the NHS albeit some long time ago, frankly I think that Sir David Nicholson should be in court for about 10,000 cases of manslaughter and all those administrators below him should be enjoined for their participation, disciplined and sacked. He does not seem to have done any “management by walking around”, if he did he must have been both blind or have no sense of smell.

The NHS would run a lot better with less than half of the current administration.

HookesLaw

You mean the Labour Party would not be focussing on a tory minister (guilty or not)?

Burnham was the minister he was a minister in a govt which promulgated a flawed target culture and a govt (and he was the minister) who saw to it that Staffs did not have a full time chief exec and indeed the acting part time chief exec was doing as far as i can see 4 jobs.

He and labour should be focussed on.

anyfool

Labour does have questions to answer. But it’s not the only name in this row,

Yes it is, Labour is the only name because every last one of the people were put in place by these self serving trash that is the Labour Party, they were put in place to serve the ends of the party not the country, that is all they do, to them whats good for Labour is good for the country.

You do not seem to realise Ms Hardman, people died in pools of urine and excrement that caused blood poisoning, they were left to starve, they were allowed to fall out of beds, chairs and slings, they died not because they were overlooked, they died because nobody cared, it was on a massive scale in dozens of hospitals.

And your worry about a slimy little man who if he had one ounce of decency he would retire from ever taking a public penny again, you seem to have forgotten that they covered up what was going on, that at least should make anyone who actually cares sick to the stomach.

Andy

I agree. I’ve been saying this for ages. Accountability starts on the Wards. Some of these killers in white coats and nurses uniforms need to be brought to Justice. The Police should properly investigate Mid Staffs. Even where no criminal offence has been committed there has been negligence on a grand scale. There ought to be sackings. I’m afraid if I had been appointed to clear up the mess at Mid Staffs I would have gone through the staff like the wrath of God.

Felix

Poor anyfool, a life that emittered must be barely worth living

anyfool

I note you do not refute what I say, just a snide comment.
Have read a few of your posts, so can see why the word embittered flows from your thoughts.

Smithersjones2013

Once again the complete ineptness of the Tory political machine is bared for all to see. You cannot attack Burnham without steamrollering Nicholson.

Don’t Tories understand that there is no such thing as an ‘I was only following orders’ defence. If Nicholson was so concerned about the targets culture he should have resigned. He didn’t. He is complicit if reluctantly in the targets culture. His complaints to ‘management’ only make his position worse as it shows he was aware of a problem. Nicholson is badly tainted. He cannot engeander confidence in the NHS. He needs to go as do a number of other NHS bureaucrats! Heads must roll in the NHS if the Tories want Labour to be held to account.

Otherwise its just another disgraceful Government whitewash and there have been far too many of them in the last two decades.

HookesLaw

Nicholson was the acting part time chief. It was labour who saw fit to give him 4 jobs.
It as labour whose drive it was to match targets and they nit pick now at targets in opposition. It is Labour Labour Labour who have turned the NHS into a political football.

http://www.facebook.com/profile.php?id=1296945479 John McClane

You cannot attack Burnham or anyone else in the Labour Party without steamrollering Nicholson.

So steamroller NIcholson and attack Burnham. Nicholson will be just one more victim to add to the 1,200 victims at Mid-Staffs (possibly 2,400 nationwide). The culprits are Burnham and the postie (his name escapes me right now) who were in charge.

Thank God for the spellchecker. I almost posted Mid-Stiffs.

http://twitter.com/Terence_I Terence Hale

Hi,
Mid-Staffs scandal: The Tories must beware focusing solely on Andy Burnham. Mr. Burnham is a simple politician who “Beats, as it Sweeps, as it Cleans’”. Sir David Nicholson is a vacuum cleaner salesman.

Russell

What a pity Burnham did’t do a bit of cleaning at Stafford instead of sweeping things under the carpet.

HJ777

One of the ironies about mid-Staffs is that it had in-house cleaning (not the private outsourced cleaning that the left and NHS unions so bemoan).

Subsequent to the scandal, they bought in private sector experts to re-train their cleaning staff.

Russell

The focus should also be on Johnson and the Labour party Isabel. It was Labour Ministers of Health, it was Labours target policy that brought about a culture that forgot about care and they should be held to account just as much as Davidson and the nurses/doctors who failed their patients.
Labour and the disgraceful ex Ministers who tried to defend themselves today in the HoC should not be defended even by their most ardent supporters. I don’t believe any journalist should try and divert the attention labour and their ex Ministers deserve by calling criticism of them as turning this issue into a political game, it is beneath contempt, especially for the families of those murdered by the NHS.
As mentioned by Cash today, calls for public enquiries were rejected, even letters to the Minister showing him the problems in 2005 were not even answered.

Makroon

Burnham was particularly gobby in the Labour campaign to get Hunt fired.
But as Ms Hardman implies, Labour are expected to play dirty.

Andy

Totally agree with you. Labour and their Ministers are very guilty. They didn’t want to know.

2trueblue

As Liebore have always used the mantra that they are the only ones who could be treusted with the NHS, it is amazing that over the 13yrs. the health of the nation deteriorated in a whole lot of areas. The patient was no longer at the centre of the organisation… so what was? I fail to think of one area that actually improved.

We are now seeing what exactly they failed to do with the health of the nation. This is also true of education, youth unemployment. The list gets longer and longer when you begin to track it all together and we are paying for it in every way. They left very little of substance behind them for their 13yrs. and they do not give a damn.

Hexhamgeezer

Stomach churning pusillanimous evasive s#!te from Burnham

huktra

Burnham is a devious man

Ask yourself this.

If he dedicated himself to Tessa Jowell(Yes she of Mills-Berlusconi) as researcher for many goodly years and then moved as spad to Chris Smith at Culture before he was sacked to make way for the said Tessa.

Just what did Burnham have to do with the Smith sacking and the shoe-in of Tessa?